A study shows that many preschoolers with ADHD are prescribed medication too soon, contrary to pediatric guidelines recommending behavioral therapy first.
A new study led by Stanford Medicine reveals that many preschool-aged children diagnosed with attention deficit/hyperactivity disorder are given medication almost immediately after their diagnosis, even though this goes against the recommendations of the American Academy of Pediatrics.
The research, recently published in JAMA Network Open, points to a gap in care for 4- and 5-year-olds. Current pediatric guidelines suggest that families begin with at least six months of behavioral therapy before turning to medication.
Despite this, medical record reviews from nearly 10,000 children across eight U.S. pediatric health systems showed that more than 40% were prescribed stimulants within just a month of being diagnosed. Only 14.1% began drug treatment after the recommended six-month period.
“We found that many young children are being prescribed medications very soon after their diagnosis of ADHD is documented,” said the study’s lead author, Yair Bannett, MD, assistant professor of pediatrics. “That’s concerning, because we know starting ADHD treatment with a behavioral approach is beneficial; it has a big positive effect on the child as well as on the family.”
Bannett added that stimulant drugs can trigger more side effects in children under age 6, whose bodies don’t fully metabolize the drugs.
“We don’t have concerns about the toxicity of the medications for 4- and 5-year-olds, but we do know that there is a high likelihood of treatment failure, because many families decide the side effects outweigh the benefits,” he said. Stimulant medication can make young children more irritable, emotional, and aggressive.
ADHD is a developmental disorder characterized by hyperactivity, difficulty paying attention, and impulsive behavior.
“It’s important to catch it early because we know these kids are at higher risk for having academic problems and not completing school,” Bannett said. Early identification and effective treatment for ADHD improve children’s academic performance. Research has shown that good treatment also helps prepare individuals with ADHD for many aspects of adulthood, such as maintaining employment, having successful relationships, and avoiding trouble with the law.
Complementary treatments
Behavioral therapy and medication, the two mainstays of ADHD treatment, have different purposes.
“Behavioral treatment works on the child’s surroundings: the parents’ actions and the routine the child has,” Bannett said. The therapy helps parents and kids build skills and establish habits compatible with how the child’s brain works.
The evidence-based behavioral treatment recommended by the American Academy of Pediatrics is called parent training in behavior management. The training helps parents build strong, positive relationships with their children; offers guidance in rewarding a child’s good behaviors and ignoring negative behaviors; and recommends tools that help kids with ADHD, such as making visual schedules to help them stay organized.
In contrast, medication relieves ADHD symptoms such as hyperactivity and inattentiveness, with effects that wear off as the body breaks down each dose of the drug.
Both approaches are needed for most kids with ADHD to do well. But previous studies of preschoolers diagnosed at age 4 or 5 show that it’s best to start with six months of behavioral treatment before prescribing any medication.
Rapid prescriptions
The researchers analyzed data from electronic health records for children seen at primary care practices affiliated with eight U.S. academic medical centers. They began with 712,478 records from children who were 3, 4 or 5 years old and were seen by their primary care physician at least twice, over a period of at least six months, between 2016 and 2023.
From these records, the scientists identified 9,708 children who received an ADHD diagnosis, representing 1.4% of the children in the initial sample. They found that 42.2% of these children — more than 4,000 kids — were prescribed medication within a month of their ADHD diagnosis. Only 14.1% of children with ADHD first received medication more than six months after diagnosis. The researchers did not have access to data on referrals to behavioral therapy, but since young children are supposed to try the therapy alone for six months before receiving medication, any who were prescribed medication sooner were likely not being treated according to academy guidelines. A smaller study of recommendations for behavior therapy, published in 2021, found only 11% of families got the therapy in line with guidelines.
Children who were initially given a formal diagnosis of ADHD were more likely to get medication within the first 30 days than those whose medical charts initially noted some ADHD symptoms, with a diagnosis at a later time. But even among preschoolers who did not initially meet full criteria for the condition, 22.9% received medication within 30 days.
Barriers to behavioral treatment?
Because the study was based on an analysis of electronic medical records, the researchers could not ask why physicians made the treatment decisions they did. However, Bannett’s team had informal conversations with physicians, outside the scope of the study, in which they asked why they prescribed medication.
“One important point that always comes up is access to behavioral treatment,” Bannett said. Some locales have few or no therapists who offer the treatment, or patients’ insurance may not cover it. “Doctors tell us, ‘We don’t have anywhere to send these families for behavioral management training, so, weighing the benefits and risks, we think it’s better to give medication than not to offer any treatment at all.’”
Bannett said he hopes to educate primary care pediatricians on how to bridge this gap. For example, free or low-cost online resources are available for parents who want to learn principles of the behavioral approach.
And while the study focused on the youngest ADHD patients, behavioral management therapy also helps older children with the diagnosis.
“For kids 6 and above, the recommendation is both treatments, because behavioral therapy teaches the child and family long-term skills that will help them in life,” Bannett said. “Medication will not do that, so we never think of medication as the only solution for ADHD.”
Reference: “ADHD Diagnosis and Timing of Medication Initiation Among Children Aged 3 to 5 Years” by Yair Bannett, Ingrid Luo, Rodrigo Azuero-Dajud, Heidi M. Feldman, Farah W. Brink, Tanya E. Froehlich, Holly K. Harris, Kristin Kan, Kate E. Wallis, Kaitlin Whelan, Lisa Spector and Christopher B. Forrest, 29 Augsut 2025, JAMA Network Open.
DOI: 10.1001/jamanetworkopen.2025.29610
This work was supported by the Stanford Medicine Maternal and Child Health Research Institute; the National Institute of Mental Health (grant K23MH128455); and the National Heart, Lung, and Blood Institute (grant K23HL157615). The study was conducted using PEDSnet, A Pediatric Clinical Research Network. PEDSnet was developed with funding from the Patient-Centered Outcomes Research Institute.
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